Sue Gedeon:
Hi everyone, welcome to this evenings trauma informed care in general practice webinar my name is Sue Gedeon and I'll be your host for the evening. Before we get started, I would just like to make an acknowledgement to country.
We recognize and acknowledge the traditional custodians of the land and sea, on which we live and work and pay our respects to elder's past, present and future.
Just a few housekeeping notes, this webinar is being recorded and will be uploaded on the RACGP website. We have put everyone on mute to ensure learning will not be disrupted by background noise. If you have any questions during the webinar please add these in the Q&A box at the bottom of your screen. You can also interact with the panelists and attendees using the chat function. We will try and address questions throughout the presentation. If we don't get to your questions, we will review these and provide a response offline. If you're not comfortable asking a question during this webinar please don't hesitate to email your question through and we'll answer it offline. I'll put my email in the chat box.
First, I would like to introduce Professor Kelsey Hegarty. Kelsey is an academic GP who has researched and taught in the area of domestic and family violence for over 25 years. She leads the Safer Families Centre of Research Excellence. The Safer Families Centre oversees the Readiness Program and our webinar series is a part of this program. Kelsey will talk a bit about the Readiness Program and the RACGP's Abuse and Violence, Working with our Patients in General Practice or the White Book guideline.
Prof Kelsey Hegarty:
Hi everybody and I'd like to begin by acknowledging that they'll be survivors in the audience and hope you know that we acknowledge your strength and resilience and you know it's such a pleasure for me to have such two stars tonight of general practice and trauma area and I'm just doing this little introduction and leaving it to them, but we have been funded both ourselves that's a Family Centre at the University of Melbourne, the College, Blue knot and Phoenix Australia to have a whole program that's about helping people to be ready to address further ready, I mean lots of you are. If I could have the next slide.
This is just the beginning of a four year program and, as you can see, if you look at the triangle on the left, the webinar series actually matches the chapters in the White Book. And so we're so excited that we're updating the White Book, the college is, with lots of help and Johanna Lynch wrote the chapter for that and the webinar series will be over the next four years. We've also got a suite of E-learning modules that we're about to release on different topics including child abuse, abuse of older people, trauma, Aboriginal and Torres Strait Islander, working with those people and also, issues around people who use violence and abuse, as well as identifying and responding to victims/survivors, and then we've got practice centred learning called pathways to safety, where we work with individual practices, and you know skill based and then we've got online training workshops that Cathy Kezelman and Blue Knot Foundation are going to be running over the next year or so as well. So it's a really comprehensive program and it'll be underpinned by a community of practice over those four years, so if this is an area of your interest we really you know it's a challenging area it's sometimes sensitive and we really trying to support primary care to move forward and I'm very excited that this is the first webinar in the series. Thanks.
Dr Johanna Lynch:
Thank you, Kelsey.
Sue Gedeon:
Great, thank you Kelsey. We'll now start with the webinar. We have Dr Johanna Lynch and Dr Cathy Kezelman presenting this evening. Dr Lynch is an Australian general practitioner of 25 years, who has spent the last 15 years working as a psychotherapist with adult survivors of childhood trauma and neglect. She is a senior lecturer at the University of Queensland researching whole person approaches to distress in primary care and teaching medical students about strengths based trauma informed care and is the president of the Australian Society for Psychological Medicine, educating connecting and advocating for GPs, who undertake complex whole person care.
Dr Cathy Kezelman is a medical practitioner, mental health consumer advocate and President and executive director of Blue Knot Foundation National Centre of Excellence for complex trauma. Cathy worked in medical practice for 20 years, mostly as a GP. Under her stewardship, Blue Knot Foundation has grown from a peer support organization to a National Centre of Excellence combining a prominent consumer voice with that of researchers, academics and clinicians advocating for socio-political trauma informed change and informed responsiveness to complex trauma. On Australia day in 2015, Cathy was awarded an AM for significant service to community health as a supporter and advocate for survivors of child abuse. Thanks Johanna and Cathy.
Dr Johanna Lynch:
Thank you all, we look forward to presenting this webinar to you today, it's both Cathy and my area of passion that GPs understand the unique role that they play in integrating life story, relationships and experiences into understanding health. We're hoping that this session will be a bit experiential so you'll leave with a couple of tools that you could use to look after yourself or your patients straight away, after being here.
And we acknowledge that some of these slides have come from Blue Knot's experience, some from the ASPM (the Australian Society for Psychological Medicine) focus psychological skills training that we run and some from my PhD. We really want this time to be interactive and so, if you have questions, please put them into the box, but to begin with, could we encourage you to write into the chat where you're calling in from today, so we get a sense of who's here and we sense our connectedness, which is quite difficult to do on these webinars and we really want a sense you're out there and we're here. I'm currently in Brisbane and Cathy you're in Sydney, and so we look forward to getting a sense of where we are scattered across our amazing country.
I will lead off now after talking through these learning objectives. We're hoping you'll see some big picture things about trauma in general practice, as well as some specific information that may be useful in your practice.
Dr Cathy Kezelman:
So what is trauma and that's the key question tonight and as Johanna said, both of us are very passionate about this topic.
So we all experienced stress, everyday stress, but trauma is something more than that. Trauma actually overwhelms our capacity to cope. And it's a response, not just a threat, but to the perception of threat. And we know that, sadly, you know we're living in a COVID world and many of us living with pervasive trauma and just the sense of not knowing and that for people who've experienced prior trauma from previous traumas. It's also very important to differentiate a single incident trauma, the trauma of an accident or assault as an adult, for repeated interpersonal trauma often as a child or as an adult relational trauma and that's called complex trauma. We'll talk more about that later, but what it does is impact, a very poor sense of self and often has more profound impact over time.
Dr Johanna Lynch:
And I have another sort of thinking about trauma, because sometimes we get tricked into thinking about trauma, from our point of view of a legal definition which is somewhat what's inside the DSM description of this topic, or an insurance based decision making framework when actually as healers or clinicians, our main task is to remember what trauma is in its original description.
It's a Greek word for wound, and so we are open to seeing the woundedness in various different layers of someone's life. The key ways that I think of trauma is it's around relational aloneness with overwhelming distress. And so, these two descriptions of what is trauma, violation of an expectancy to be safe with another person or repeatedly being left psychologically alone in unbearable emotional pain.
These two, I think, help us to not miss the kinds of trauma that should do with absence or disconnection that happens for people inside their homes and workplaces and schools. And we'll move on now to more about how common is trauma.
Dr Cathy Kezelman:
You can say trauma is very common, because as Johanna says it's about abuse and violence and what we see but it's also about neglect and what people don't receive in terms of attunement and attachment. And we know, sadly, that it's incredibly prevalent. Blue Knot works with survivors and complex trauma and we estimate conservatively that more than one in four adult Australians are living with the impacts of that sort of trauma. I mean I'm not going to read out the stats here, but we know that the impact of trauma is cumulative so when someone's experienced trauma before and they experience repeated trauma, often they have compounded impacts of it.
What's very, very important to say though, is that even though the impacts can be profound, the people with trauma show incredible strength and resilience to have survived, and we have to hold on to that strength and that hope of recovery and possibility and we know that even though the stats are you know quite horrifying in a way that 90% of public mental health clients have been exposed to multiple experiences of trauma, we know that people can and do recover and that's not just anecdotally, that's from the research.
Dr Johanna Lynch:
That reminds us of the concept of post traumatic growth that so much of us lived through. But just bring to your attention the key research work in this space started by Vincent Felitti and Robert Anda population study of 17,000 middle class Californians and followed them forward for 20 years. They retrospectively reported on their childhood trauma experiences in these 10 categories of abuse neglect and household challenges or dysfunction. And they also followed them forward into the hospitals, morgues prisons, etc, to identify and showed a dose dependent implication of these. The more that someone had of each of these, the more likely it had an impact on their whole life, function and health.
Since then there have been studies that have taken us beyond those 10 original adverse childhood experiences, and these are some of the areas where we know they have impacts on health and wellbeing. And there's studies done by Martin Tisha in Boston that also has confirmed the importance of impact on brain structure and function of peer bullying, witnessing your siblings being hurt or experiencing non-verbal emotional abuse which is really the silent treatment, and we see even that happening for our teenagers long in the social media land of ghosting, being left alone in the sort of virtual world.
Dr Cathy Kezelman:
So why do we need to talk about trauma. Trauma is part of the human condition, and you know there's no them and us to trauma. Many people listening today will have experienced their own trauma. And I certainly know that you know when I was working as a GP and I started having to deal with the impact of my trauma, that I wasn't prepared as a GP to understand what was actually going on and that's why it's very, very important that we keep it on the radar because every day people will come into every general practice and will have an experience of trauma that is impacting them in some way, and GPs are in a very unique position because you have a relationship with the person, you have a relationship with the family and you understand the context of the person in terms of their culture in their background, and so that's a unique relationship that can help you understand how that they may have a trauma experience and you may not need to know the details of it, but it may be presenting in a particular way and that's what's very important to think about it, think about the possibility, because if you don't, you won't recognise it and understand it and therefore, be able to support people in the right way to be able to address it.
Dr Johanna Lynch:
Yeah and I think this brings us to the unique GPs scale a pattern recognition and also knowing what health looks like in order to build towards where we're going with healing and so, in the era of trauma informed care in general practice, my research and that of others really prioritised stabilising the person in helping them have that experience of feeling safe.
When we asked people what sense of safety was, it was a whole person experience. They described sensing themselves, but in a certain context with a certain person either with them, or who they knew was supporting them in some sort of perceived level of support in their life. And they noticed how connected, available, attuned with them on their side people were, and also how capable they felt to engage with the world and that sense of in the middle of that is an integrative experience of feeling a sense of safety.
Dr Cathy Kezelman:
Yes, yeah I mean many people who've experienced abuse or violence have never felt safe, and I think it's really, really important to understand so it's not just about restoring a sense of safety, but you know it's about being patient and taking the time until a person can actually understand what that feels like. Sorry to interrupt.
Dr Johanna Lynch:
Yes absolutely I think that this is where we're going and in terms of how we handle someone from the first moment they walk into our waiting room, through to how we arranged the seating in our rooms, so that they have choice to feel as safe as they possibly can, through how we do consent, how we write letters, how we don't have secrets about them and how we write to other people we let them know what we're writing about when we're sending a referral letter of any type and how we give choice and collaborate with them and we will prioritise those as we go through today and, in some of our conversations about the principles of this work. But to say, this is our antidote to feeling traumatised, and this is where we're heading in in our treatment.
It also helps us, then, just like a normal blood pressure, helps us know when something's not right, up or down, to pick up subtle changes that are signs that someone is not okay. These three things are part of what helped people to feel safe, the sense of their own integrity, physical integrity, but also their sense of identity and sense of their place in the world, a sense of coherence of their internal understanding of their emotions, their physiology, levels of arousal and their connectedness to other people and to the wider community, and a sense of connection to other people. When those things are threatened through disconnection, confusion or invasion, human beings get threatened, their arousal systems are activated, they go on to vigilant states on guard and, in extreme cases will go into shutdown or paralysis.
And so us as GPs, being aware of these patterns can help us to notice all the different ways that people get invaded with expectations, with demands, with physical attack, with sexual abuse, with trapping and financial abuse, the ways they get confused and in domestic violence, we talked a lot about gaslighting, where people are intentionally confused by those they're trapped with living and other forms of confusing double binds in relationships, where, if you if you do one thing there's no win situations. And then disconnection ways that people disconnect and turn away from each other are all really just things we can pick up in general practice early and part of early intervention in the space.
Then move on to the concept of toxic stress. There's a big literature which has been building over the years since the original definition of the word stress from a medical student in in Czechoslovakia in the 50s or 40s and since then, a large body of research is built on our understanding of the physiology of stress and that it's linked not just to physical stress like infections or violence or a physical trauma, but also from psychological and sociological trauma or threat.
And so the idea that we have used stress when we're doing something like this for my presenting it's normal to feel a little bit of stress and to keep on going and doing that and that cure for that is practicing keep on doing it. Then at the other end is toxic stress where it's completely overwhelming to the person's physiology to their resources relationally and sociologically. And in the middle is tolerable stress where something overwhelming can be made, be buffered by the presence of another human being and that's where relationships are so important in our understanding of the causes of trauma, but also the healing of trauma.
We move on, this concept came from the slide on the right image, there is from a fantastic new resource called number story.org. And, and I've sort of summarised the impact of adversity, some of the physiological neurodevelopmental disruptions, stress and immune systems dysregulated, metabolic cardiac and autonomic nervous system arousal changes and regulation alterations, epigenetic changes and then for the GP also watching for changes in arousal and behaviour, perception, how they connect to their body which can come out in somatic presentations of something that's a memory or a heightened awareness of the body or a disregard or disconnection from the body that leads to late presentations with certain physical illnesses we see disrupted social relationships and negative sense of self and we'd also see a sense of fragmented sense of self impacted by shame and sophisticated coping mechanisms to manage these dysregulate of arousal and that's my labelling for what others might call addictions, I see them as sophisticated coping mechanisms to manage what's the body's doing from early childhood on into their life.
And we're not going to cover this, but this is just showing you the resources, you can read on the new roadmap to resilience from the California surgeon general's report on adverse childhood experiences toxic stress and help. To give you a more robust sense of wide as GPs this isn't just soft science to be interested in people's life stories or their relationships or their internal senses or emotional experiences. This is actually important for us to understand, as people who care for physiology for early intervention in health trajectories and for understanding the more complex presentations we may see in our caseload, whether it's complex pain, multi morbidity of many different types, it's medically unexplained illnesses and all so much more that there's going to be new science helping us understand our time if we stay abreast of it.
This is just a quick summary from the ACE study showing some of the key areas of behaviour, physical and mental health that have changed as a result of adverse childhood experiences and I found independent risk factors for physical and mental health that are significant in areas of high importance to our health community. If we look at their studies, they talk about adverse childhood experiences dramatically increasing the risk of nine out of 10 leading causes of death in the US. Our top five causes of death are circled in red and then I've numbered the others there, so we have ours, we match them on diabetes but some of the others are in different spots.
But just to raise awareness that trauma informed practice is deadly serious for our public health purse, it's important for our diagnostic decision making, but it's also important for how we see the person within their life story and their health story. If you wanted to learn more about the pathophysiology of this, this new research and writings on allostatic load, which is where the body can no longer return to homeostasis because of threat, and it has to adapt and create a new set point down a static set point and at some point that gets into overload, which is where we will see disease.
And finally, the last pattern I bring to your attention is bringing us back to why we do have diagnostic labels in this space. I see these are the tip of the iceberg of what we see in general practice, that's where life stories impacted health. But they're important for us to notice and they now have names and have been identified and named in the ICD-11 and DSM. And these are the patterns, we already know about PTSD, avoidance, hyper vigilance, and re-experiencing, but also affect dysregulation and negative self-concept, relationship disturbances, altered connection to body, altered systems of meaning and altered physiology are listed there.
And I would add as a GP altered states of consciousness that we often will see our in our work. I'll now handover to Cathy for a bit more about possible presentations.
Dr Cathy Kezelman:
Possible presentations as you're gathering from Johanna, they're pretty broad and many of them are related to as far as an overactive fight flight freeze response, never reaches back to homeostasis so people are staying allergic distress and often hyper aroused or Hypo arouse so waiting for the next danger. And people struggling with the impacts of trauma find it very hard to go back to what we call the window of tolerance, the level of arousal for which we function optimally and many people experienced very strong emotions as well with these variations and arousal. Johanna talked about also PTSD and the symptoms of it and flashbacks and fragmented memories here, so I mean, certainly with my own experience when I was starting to relive the impact of my trauma I didn't know what a flashback was, and there I was in my mid 40s being thrown back into reliving experiences as a 4, 5, 6 year old, experiencing the fear and the sensations and the movements in my body.
Other possible presentations and we've talked about a lot of the somatic presentations, fibromyalgia, chronic pain syndromes, irritable bowel, Crohn’s disease. The list just goes on and on, and so, if you don't have trauma on the radar, how do you actually recognise the possible presentations of it and, of course, the impact on interpersonal relationships and very core sense of self, your relationship with yourself your relationship with others, your relationship, the world.
And another major impact of trauma is an overwhelming shame and sense of self blame and that sense of shame can be totally withering and it's part of the reason that people struggle to engage.
So what might alert us, and not to say that you know all of these presentations or lack of presentations mean that someone's experienced trauma but again, you know puts that little reminder for us to think about trauma and people who have experienced trauma, obviously they've been betrayed in primary relationships and they felt disempowered, so why should they trust. And so they're going to be very reluctant to come forward to seek help and certainly to come to see a GP for what are often quite invasive procedures and even taking clothes off for standard physical examination is intrusive to someone who's been abused. People may make appointments and then fail to turn up, then maybe quite chaotic in the way they engage with you, they may present only in crisis and then disappear, so there are all sorts of ways that people may be subtly giving you some sort of message that there's something else going on behind the presentation, or lack of presentation.
Dr Johanna Lynch:
And I'd add to that Cathy, those who are looking high functioning with severe workaholism, for example, or achievement addiction of certain types that might look as though everything's nice and neat on the outside, but there's a lot of paddling under the water of what managing their experiences and their memories.
Dr Cathy Kezelman:
Well that's right and we talked about coping strategies before and coping strategies can range from you know, alcohol and drug to you know excess work or eating or you know gambling or all sorts of different ways of trying to calm a nervous system that's in distress.
Dr Johanna Lynch:
So we thought we'd bring us back to a definition of generalists and that just reminds us how trauma informed care is really what good quality general practice looks like.
We define generalism as person not disease orientated, continuous rather than episodic in its care and integrating biomedical and biographical understanding of illness and I would say, of the person, in order to support the progress towards health. And I guess, I would see that trauma informed care in a way, is code for what we as GPs would do if we were doing our job well and I really believe that most GPs are, we're just trying to help hone their work to see and sit with and notice what's in front of them in each person they see in their work.
But again, to say that trauma informed care isn't an add on to normal general practice it's not something we just apply to a certain subset of our patients or a certain caseload, it's actually a way of seeing the person and how their life story integrates with their health.
Dr Cathy Kezelman:
If I can add to that. Trauma-informed care has been bandied around too much, but what it's really about is being human and seeing one another in all our humanity and respecting the other person honouring where they've been, where they've come from and what's happened to them along life's journey, and we all have impacts along the way.
So how do we become empathetic and understanding and GPs already are, this is what GPs do every day so yeah, as you say it's not an add on it's about embedding it even further into practice.
Dr Johanna Lynch:
Yeah and helping us see the amazing risk people take to trust us with their stories and the position we've built with within our communities for them to be able to do that thing, of telling us something that's very shameful to them.
Dr Cathy Kezelman:
I suppose trust is very difficult when you have been so betrayed and when society has traditionally turned away from lots of issues and treated people with stigma and ostracised and often blamed people for their own victimhood in many ways, so how do we become a compassionate society and relational healers in our practices.
Dr Johanna Lynch:
Yeah and, to be honest, I think trauma-informed care is an antidote to reductionist medicine that only sees people as bodies and diseases to be diagnosed and tests to be done on as objects. It encourages us to notice the internal sensory experiences of people, the personhood of the person, how they see themselves, how they see themselves in relationships to other people, how they fit in their own community and culture and environment, and so it helps us remember who we are as GPs I think.
Dr Cathy Kezelman:
I think it also encourages us to check in with ourselves in the same way.
Dr Johanna Lynch:
Absolutely, and we hope to do that, towards the end of our time today as well.
As part of my thesis I asked the question, what causes threat, and I think you know, in some ways, we could call this wide view of trauma threat informed care and as Cathy noticed at the beginning perceived threat informed care as well. And that idea that we should notice someone's environment, their social climate, including their social media climate, their personal relationships, how their body is experiencing the world, their inner experiences that are not just thoughts, they're also memories, perceptions, how they pay attention, and that you know that's where flashbacks might experience, their sense of self and then any meaning or spirit that helps them to make sense and makes the world more coherent for them.
Dr Cathy Kezelman:
So talking about trauma in primary care, and this is an unapologetic plug for a publication that blue knot has produced, and you can download this for free or purchase it. And it really focuses on why it is important to understand about trauma, building trauma literacy, but also talking about how to build a practice that's truly trauma informed, as well as your own personal practice and this Johanna was talking about.
You know, coming into a practice and coming up to the front desk and being ignored, is something that can be profoundly triggering to someone who has felt disempowered previously. So how do you make the whole space welcoming and feel as safe as possible for someone who you know, maybe living with a sense of being heightened all the time, but is particularly heightened because they're coming to see the doctor who is in a position of power for people who have been abused and disempowered.
And so, how do we engage with people who are impacted by trauma and recognise that some of the presentations they're not going to come in and say I've experienced complex trauma. But some of what they're telling you with the way they're engaging or not engaging in some of the way their presenting is giving you that message, so this is about really raising your radar around trauma and of course this isn't about training, training can build on this, but this is a very good start.
So why is it important? Well for all the reasons that we've said, we know that trauma is just a substantial public health issue, it impacts, you know the physical, mental health of society, of individuals of families, of communities. It has profound impacts economically on lost productivity, people who have experienced or more often have struggled to finish an education can't hold down a job or experienced a lot of absenteeism. People may present in crisis, often because of the coping strategies that they've used to try and calm their distress, often use a lot of services, or because they don't use services, present again in crisis. So it's critical, because it is such a substantial issue and it affects everyone's patients everyday profoundly and so it's just so important as part of health promotion and primary care to recognise it and try and intervene early.
So why can it be hard for patients? Well you know patients who have experienced trauma, as we say, have often not felt safe, they've often never felt safe, and it can take a long time for people to feel safe so it's very important to be patient and not to push people at a pace to speak about their experiences that they're not comfortable with. It's very, very important to know their personal space. We talked about a sense of shame, which can often be overwhelming. Many people who've experienced abuse as a child came to believe that it was their fault, particularly when people have been abused by a family member, the very person that they depend on for their care and nurture, how can a child make sense of this. They've been told to keep a secret or society is actually exacerbated that sense of secrecy and shame. There was a Royal Commission a number of years ago into institutional responses to child sexual abuse and the secrecy and the power imbalance that came out in that Commission was just startling, 4000 of our mainstream institutions were implicated, and it shows that you know, it took enormous courage for survivors to come forward and to speak out and to be believed, and being believed is just so critical to survivors, and we know that often because of impacts on memory, it can be very, very hard for survivors to tell a coherent narrative at times because their memories have been so impacted by the trauma. And therefore often they're not believed or they're often isn't a witness to a violent act. It doesn't mean that the trauma didn't occur. And what we know is that very sadly people seeking help and seeking support and seeking justice have been re-traumatised in that process. So I suppose the key message here is, you know to be very gentle and to know that disclosing, if someone is sharing a traumatic experience with you, they're really putting enormous trust in you and it's a matter of just being there and listening and hearing and walking alongside them.
So why can primary care settings make it harder? Well primary care settings can be really scary and anxiety provoking, particularly for people who have been in a disempowered position when people have felt violated or exposed. I had someone just email me the other day and she'd been triggered by being told that she needed to have a COVID jab. Now the word jab for her was violating and intrusive and people who have experienced trauma can be very readily triggered by things that may appear very benign to others who haven't experienced trauma and it's often a sensory cue, a sight, a sound, a smell, that can throw people right back into that time of trauma when they were disempowered and they were being abused or violated. Obviously, many procedures, medical procedures and as a GP can be very hard to think about your procedures as being invasive, but for someone who is non-medical, they can be quite invasive and hospital settings also can be quite scary. Removing clothing, asking someone to lie down can be very intrusive, particularly for someone who's experienced trauma.
So, which patients are more likely to have trauma histories? This statement typically than the most difficult patients of the day I don't know I mean I've got a lot of admiration for Felliti and Anda. But I wouldn't say the patients are the most difficult, you got to say what happened to them was most difficult, and trauma is about having experiences of something that someone should never have experienced and it's about how it affects you physiologically, and how it affects you in the way you present and, often, yes it is people, patients with unexplained symptoms and you can't work out what's going on, it doesn't mean that they're making it up or it's not real. Yes it may be challenging, they may be hard to help for all sorts of reasons and, as we said before they can be quite erratic in sort of coming and not coming and often not very good at maintaining the health checks and therefore often you know exacerbate even further the impacts of the trauma on them, on their medical health.
Dr Johanna Lynch:
Yeah and I would add that, and having normal experiences to abnormal experiences.
Dr Cathy Kezelman:
So trauma informed practice, as I said, this is a term that's been bandied around and people think it's about clinical treatment. It's not about clinical treatment, it's about thinking about the possibility of trauma and, as we said before that you know along life's journey, many of us experienced trauma along the way, but it's also about thinking about the particular sensitivities and vulnerabilities of people who may have experienced trauma and how that impacts the way we engage with them and how they may respond.
So the trauma informed principles, they look quite simple and they're quite simple to articulate but they're actually very hard to embed on a daily basis and it's all about actually thinking about the person that we're engaging with, it's not our definition of safety, it's what is safety to them, what is safety to them emotionally and physically. Some people never feel safe, never are safe. People experiencing domestic violence today, they may come to see you but they're going back to a very unsafe environment. People who've been betrayed, why should they trust you, you need to build that trust, you need to show that you are reliable, that you're consistent, you do what you say, and when you don't deliver on what you promised that you own it. People who have experienced trauma have often not had a choice. Their choice was taken away from them. I was in my mid 40s before I actually understood that you know, try to even imagine what it was I liked, because that wasn't something that I ever asked, I didn't even know I could. And it's about really collaborating with someone, working with someone and sharing the power, again disrupting that power imbalance and power over so that people feel that they have autonomy in their lives and a real say in what happens to them.
It's very, very important to understand that people who've experienced trauma are absolute experts in their own lived experience and you know it's about engaging with them as they want to share with you about that experience.
Dr Johanna Lynch:
And I'll cover some first principles of trauma informed care that have been outlined in this chapter, trauma informed care in general practice in the White Book that's about to be released.
I see these slight antidotes to reductionist ways of seeing people as reminders about the dignity of people and the importance of physiological experiences of arousal when we're trying to understand what's going on for people who have experienced trauma and in fact, for all of our patients. These are principles GPs can use with every consultation.
We prioritise the person's safety in the room, with us and how we engage with them, but also in the wider world and what's going on for them in their housing, their finances, their relationships, their workplaces, their school yards. That we foster their capacity to soothe physiological arousal as a key skill that we know how to do for ourselves, and we know how to teach and we facilitate people learning how to do it when they're calm, so they can have access to it when they're not feeling safe. We validate them as a person, and we validate their perceptions of what has happened to them and what life is feeling like right now. We collaborate and empower with them as Cathy's reminded us, and we connect and stay involved with their care, so we offer them a different experience to one they may have experienced in relationships with other people.
Where we will remain what one GP writer talks about abiding with our patients beyond when technology and medical advances have nothing left to offer. This is one of the unique things we do in general practice, we stay with our patients while they face the realities of the life they're actually living. And so, this position of staying with in relationship for the long term thought through the thick times, we have to say, sorry to them for our mistakes. Through the times when they suffer things we can't imagine or even bear sometimes and so these are the key principles that are outlined in that chapter of the book.
Dr Cathy Kezelman:
So safety. There are lots and lots of dimensions to safety and we can discuss this for weeks, but we're talking about here, safety in ourselves and many people have experienced abuse who have been violated, feel that their bodies have actually betrayed them and people can actually hate their own bodies. And they often find that they can't control their levels of arousal and very strong emotions and often their thoughts as well. Interpersonal safety, you know, obviously, when you've been harmed by another person of course you're going to feel unsafe in relationships. And you know, often intimate relationships obviously are incredibly difficult and that's why you know, even the most trivial of interactions can start to change the script in a person's head that you know other people are dangerous. I once met you know someone who had actually given up on humanity, he had actually gone and lived in the bush, for I don't know 10 plus years, until he became very, very unwell and then he thought he'd give humanity, you know one more chance, he came back and he reconnected and he's now you know, a university lecturer and you know reconnected with the sense of safety, he just gave the world one more chance. He'd been so harmed by other people that the world was that other people would dangerous.
Many people who are unsafe in their environment, particularly people obviously living in domestic violence, but we know that even if your surroundings are not necessarily that unsafe can still be triggered because something reminiscent of the past throws you back into that time of being unsafe and systems definitely can be unsafe and institutions, and I suppose in general practice, you know how can we have a practice that is as safe as possible, and as attuned as possible to our patients.
Dr Johanna Lynch:
I think these things raise our awareness and integrate some of the other areas of research, such as social determinants of health, our understanding of intergenerational trauma that's passed down and the impacts of environment in racism and injustice, migration, many of the things that our community carries with them under the skin into our rooms. And I see this way of seeing helps us as GPs, to have a very integrative understanding of how health is impacted by environment, life experiences and relationships.
As we get more personal about that intrapersonal levels of sense of safety and the connectedness of our patients to the places of safety in their world and we see what are our goals, when we're caring for someone who's experienced trauma and I would see these have come out of some of the greats who have written about trauma, who first brought to our attention the experiences of trauma within people's homes, talked about establishing safety, having a period of remembrance and mourning about what happened and then reconnecting with ordinary life as stages of healing in the space.
The Blue Knot Foundation would talk about it as stabilisation, processing and integration. I see them as a moving that people go through these stages backwards and forwards as different parts of their story come to light, as different resources are available to them. And some people will come having lost a sense of safety, actually, at a time when their lives are pretty much the most ordered they've ever had because it's now safe enough to feel and so they'll be bemused or perplexed about why now when everything seems to be going well, am I remembering these things and so just normalising that we actually manage our dose of our memories. We have exquisite personal kind of attunement to what's possible and what we can cope with and bear and so, if someone's bringing something to light, we can be reassuring that something important is going on that they that they can work through.
I see that our goals are to build a sense of safety in someone's life in small micro moments of experiences of relationships and nature and physiological calm so that they feel safe enough to grieve what's really happened. And this doesn't mean we have to listen and make them tell us the story of what happened, but that in the their responses to their current day to day life, they can grieve the reality of what they've lived through and that enables them then to feel safe enough to grow.
If we then move to a sense of prioritising safety we want that to be in their environment with the people and relationships that are around them in their body, in how they see the world and the sense of self and meaning. And again, the centre, that whole person that we're trying to help. This is not about symptom control, it's not about diagnostic precision, it's actually about someone's experience of themselves in the world.
Cathy mentioned earlier the idea of a window of tolerance. This came originally from John Briar. The idea that when we're caring for someone, we don't want them to tip outside of like we do with drug doses we don't want to have too much of a dose or too little and that when changes happening in therapy, we want someone to be able to feel and think at the same time, and if either of those have gone offline, that either not feeling or not able to think straight, then they can't leave not feeling safe, and so our task is to bring them back. If they're feeling too much emotion, we bring them back to noticing something in their physical environment, and using language and conversation and even humour, which GPs just do beautifully most of the time, to help our patients come back to us from wherever they've been that's distressing in their hearts and minds. Or they may be too cognitive, telling us long winded stories that are not actually connected to what's really going on, repeating a story that they've told 100 times before, and one of the key clinicians in this space that I've learned from, Janina Fisher, talks about empathic interrupting when they're doing that and bringing them back to their bodies and noticing what's going on for them right now in the room, as a way to help them manage that level of arousal.
We look at Maslow. Maslow talked about human beings as safety seeking organisms and he wrote before the disciplines and broke the body up into parts to be studied in minute detail. And he noticed a pattern that human beings looked for safety and he named it as a hierarchy, I see it, more as each layer of his hierarchy is a search for safety in a different part of the person, and I would put the body, the calm body as a central piece of that puzzle. He talked about our physiological needs for homeostasis and he talked about needs the stability and protection, freedom, structure order, law and limits. He talked about the giving and receiving of affection and the sense of mastery competence and deserved respect and dignity.
As well as becoming everything we're capable of becoming and you saw them as something that built on each other. I see now actually people sometimes become the most amazing human beings when they're in the most physiological deprivation and so the idea that this is something we all can do at different stages, it flows backwards and forwards and as GPs, we can build someone sense that they have a calm body, that they have safe places to belong, that they can feel safe on the inside, they have safe places to be and safe enough to grow.
We've asked to take questions for the clinician to consider. What is causing threat for this person? It could be in the present, it could be in the past, it could be in the future, and how can this person experience or sense safety?
As our key medical conditions when we're trying to care for people, whether it's giving them a diagnosis of diabetes or helping them understand their children's behaviour, these questions are useful.
Then we ask this task of tuning into the wounded, rather than a disease focus, which is looking for what's wrong with you, we can move to more of a trauma focus, what happened to you and I would want us to shift the conversation to the strength based focus of how safe are you feeling now, and how can we help you build that safety. And what are you already doing successfully to feel safe.
Dr Cathy Kezelman:
To build on that, I mean many people who have experienced trauma really struggled to acknowledge their strengths and so part of this is to actually help people to recognise their strengths and then to build on it.
How do you ask about trauma, and this is really about not digging into the details of people's stories, but actually asking around, how it's affected someone or where there any painful experiences that you have as a child, how do you think your health method been impacted. And just taking a measure of the person's level of window of tolerance, you know, the level of arousal and helping to ground them if people become distressed and also, obviously, providing people with the right support and follow up and referral as required.
Dr Johanna Lynch:
And I'd add that Cathy, when I first started doing this work, I thought, just like a good medical history taker that I should know all the facts. And again, Janina Fisher oh no, it was actually Christine Courtois, she talks about the idea that safety takes precedence over story, and so that the questions we ask shouldn't be making someone feel unsafe in as much as we possibly can.
Dr Cathy Kezelman:
Yeah.
Dr Johanna Lynch:
And so, knowing the facts is the last thing we need to know and as I've gone on in this I know less and less of the actual details of what happened to someone and more look for the patterns of how to help them get back to safety.
Dr Cathy Kezelman:
Yeah and I think that's a big change in the way trauma is treated than previously, there was this belief that you had to dig into the story, and you had to bring it all out, that that was the only way that someone could heal and recover and that's certainly not the belief now.
Dr Johanna Lynch:
And I think, also from a diagnostic formulation that we got to say from the outside, what was and what wasn't traumatic based on how life, threatening it was. That shift away from that to being the person being able to tell us from their point of view.
Dr Cathy Kezelman:
Well exactly. the person's perception of threatened danger, not ours yeah.
Yep so principles for engaging with people with trauma history, and I think we've spoken, you know very much about safety, but I don't think you can talk too much about safety. That is the core, and you need to keep coming back to that at all times, because you know it's quite easy for people to lose connection with that sense of safety.
Being very aware and certainly being very aware of your own reactions when you're supporting someone who's experienced trauma, because you need to stay tuned into yourself, you can't help support someone to ground themselves and to relate if you're not grounded yourself. Being very aware of the possible impact of trauma.
Very important to take this strengths based approach, and you know I'm medically trained as well, and I was brought up on diagnosis and what's wrong and not to say that we need to throw diagnosis out of the window at all, but with trauma, we know that it's very much what happened to someone and how that affected their physiology and how their physiology has in turn impacted them, as well as how they've coped along the way, and then the impact of those coping strategies.
Many people who have experienced trauma have experienced issues with the attachment with primary connections and it's relational trauma and if your schema in your mind for relationships is that they're unsafe and you can only rely on yourself, it can take a long time to build a trusting bond, and we know that many, many people who have experienced trauma tend to withdraw and isolate themselves and not reach out.
Maintaining hope and the possibility of recovery is very, very important, and you know, sometimes you know people can lose sight of hope. It's very, very important that the person that they're engaging with, particularly if a physician can hold on to that hope for them, not to be Pollyanna, but to know that people can and do heal from even the most substantial early trauma.
Dr Johanna Lynch:
This is another one of the patterns that we can have being in the community with people who overcome and recover and live with pain. We see people who are in the height of their distress, and we see how they recover from that so we can lend hope to our patients who are not yet there.
Dr Cathy Kezelman:
Yeah and we can you know, bring in all of the stories recovery that we know, because it can be as challenging as it can be to alongside someone who's experienced trauma, it can also be incredibly inspiring to understand the resilience and as Johanna talked about post traumatic growth that we see, that people are remarkably resilient.
And again not to dismiss you know that you know, some people, of course, you know really struggle with quite profound depression and suicidality and self-harm, and you know, obviously it's a matter of supporting people but understanding again why people struggling in that way, and that they are coping at that point in the best way they can and that's their coping mechanism time, not to ignore the risk because it's very important to obviously assess the risk and do what's appropriate but to understand this is all part of the dynamics of trauma and the way it can present.
Dr Johanna Lynch:
So I just move on to a couple of skills to think about in your practice and this one comes from Bruce Parry, listening to him during COVID actually talking about how we need to regulate before we can relate with other people so regulating our body again bringing us back to that calm body as a goal of care.
In order to relate to another person, and only then can we reason with them so giving information after a diagnosis, for example trying to reason with someone around motivational change, for example, they can't work unless the person has a calm body and is relating to you, so this is just a practical thing to keep in the back of our mind when we're trying to do some of our general practice tasks.
There is a skill I teach routinely to my patients when they're calm, so that if I need it in the consultation to bring them back into a window of tolerance, I can use it, but also so they can use it at home and a way to ground this into their home is to do what we call anchoring where they can go to each room of their house and choose an object in the room that they will go to if they're feeling aroused or dis-regulated and to carefully name what they see, hear, feel, smell, touch and so on.
In the room, we just teach them these three senses and talk about how we're trying to get the brain to reconnect to itself if we bring in our sensory fibres into the brain, what we call bottom up soothing, just noticing I'm in a boring room with some paintings on the wall, with a light on, the sound of the air conditioning, the sound of people in the waiting room and I can feel the chair and my shoes and my feet inside my shoes and my watch on my arm. All of those things are sensory information that the body can use to remind itself it's not somewhere to be terrified.
From top down, we then use language and sentences making our motor muscles in our mouth and our vocal cords work to say these things out loud, and so I say to people I know it sounds a bit strange, I'm going to ask you to actually say what you're seeing and hearing and feeling, and we'll name them one by one and if you can name three of each that would be really great and so that way of normalising trying to get the brain to reconnect to itself is part of learning how to get a calm body, of course, the beautiful things in the mindfulness space and we'll talk a little bit about about other things that buffer a sense of connectedness to ourselves in a couple of slides.
Dr Cathy Kezelman:
Looking to be in the present to you know when you've wanted to escape from the present, at the time of the trauma can be very difficult, and obviously there are all sorts of ways that people can escape so as you said, bringing yourself back to your body and reconnecting is absolutely critical.
Dr Johanna Lynch:
It is, and it's not easy.
Dr Cathy Kezelman:
No it's not easy. So just as people are harmed in relationship, so people can be healed in relationship and it's just you know really critical to know that every interaction you have with someone that you're engaging with is important and every interaction people who've experienced trauma, a hyper alert to any cue and they're just watching and waiting to see do you genuinely care, are you really wanting to engage with them, are you safe with them, can you trust them. And so you know you can be a mechanism to help people heal and you can do that in every time you meet with them.
Dr Johanna Lynch:
This actually comes from the roadmap to resilience group but it's also profiled on the website after story which comes from the amazing work of Nadine Burke Harris. She's a paediatrician and public health physician in the US, she has a Ted Talk on the topic of trauma that I hope all of you have seen.
In this slide we're just reminded of the things that have some evidence around helping people to calm, including sleep, diet and exercise but also mindfulness practice. Nutrition prescriptions for nature and supportive relationships, as well as caring for mental health.
And if you haven't seen Nadine's Ted Talk or read her book, there's a podcast done by MHPN where Cathy and I talk about her book. I'd highly recommend those resources.
Dr Cathy Kezelman:
Yeah, The Deepest Well. I hadn't read it, but when Johanna recommended it, I couldn't put it down it's really you know quite profound and underpins everything you've said today, I think it's really important.
Dr Johanna Lynch:
Yeah it's readable and told in clinical vignettes that help the clinician to remember. We look at this idea of goals or trauma informed care, we want someone to have a calm body for managing pain, managing acute risk, helping them to ground with the senses and empathically interrupting them in the clinical room to keep them in the window of tolerance when they're with us. So that every time they come to our room they're not expecting something frightening, they're getting repeated experiences of something secure happening. We want them to have a sense of connection and therapeutic relationship with us and continuity of care, but also for us to notice their connectedness to their own community, culture and our personal relationships.
And we want them to have a sense of being safe on the inside, so that experience of shame and managing and helping shame, which is a terrible sense of being disconnected from other people, is a key element of treating trauma and so, if you have someone who's got extreme shame, I urge you to find your local trauma specific therapists who know how to care for and heal in the space.
Of course, in that space is also how we treat someone with dignity and meaning and validate and offer affection and kindness. We want them to have a sense of a safe place to be at home, work or school, our therapeutic space, our waiting room, but also their housing, their finances, and access to health care and then in the area safe enough to grow, we want to help build their capacity to empower to collaborate to have choice.
And the way we ask questions, the way we see them, the way we think about possibilities for the future, the way we lend them hope, it's part of that.
I'm now going to move on to a little bit of a section about self-care, unless you have anything last you want to say on this section Cathy.
Dr Cathy Kezelman:
So self-care, and you know, having been a GP a while back, I know that you know, certainly the GPs in my practice were very, very bad at looking after themselves, and so I mean hopefully that's improved over time. But I think you know it's a demanding role, and I think it is easy to forget about yourself but you're very important and you can't care for others if you're not able to care for yourself.
How do you currently care for yourself, you know what is it in your day that helps you bring your nervous system back down to a calm space? Do you have a wellness plan, is there something else you can put into in place?
Are you in tune with your own body, are you able to measure when you're actually going outside of your window of tolerance, because you know it's a physiological response we all do, and if so, how can you bring yourself back? Do you have any sense of a work life balance, and I must say, you know I find this a difficult concept myself, because I struggled to find one, but you know, I do have different ways of caring for myself, so I suppose over time that's something that I'm still struggling for.
And you know from where do you drive your sense of meaning, because we know that when you work with people who have experienced trauma, that can impact your own sense of the world in your own sense of safety as well, so you know, how do you connect back into your own sense of meaning?
Dr Johanna Lynch:
So I actually just want to give you a little moment now to think of a place where you sense safety, it could be a certain chair in your house, it could be in the presence of certain people, it could be a view on holiday, it could be a window that you look out of, a garden that you sit in, a piece of music that you listen to, the feeling of the shower, the smell of some flowers in your garden or a candle. It could be the feeling of strength, while you're doing something or making something.
Just if you can notice somewhere where you sense safety and then I'm going to walk you through noticing the seven senses that are really important for us as human beings, as mammals, who orientate ourselves to our environment and notice our senses. The five sense that we normally know, but also proprioception, where we are in space and interception, what it feels like on the inside of us, so if you can think of that place right now, see if you can just get a sense of what you might see if you were there. And then notice what sounds might be in the environment. What things you might be feeling with touch, it could be a breeze, it could be a place you're sitting, the feeling of the environment.
Anything you might smell if you were there. Some of us might be doing this over a hot cuppa of something, something you might taste. And then notice your body in space. Where are your shoulders, where are your hands, where are your feet. And then slow down and do what an Indigenous Elder called compute on the inside. What do you notice on the inside?
And if you can, just see if you can name this place, with one word, one word that would bring you back here if you thought of it.
Okay, and then I’ll just get you to start to notice, where you are now. Notice the sounds, the temperature, where your body is right now in the chair, unfortunately not in your wonderful safe place, you're listening to a webinar.
And then, when you're ready just re engage with us here, and if you want to you could share in the chat box your one word of where it is you went to feel safe, that is something you can do right now and we can share a sense of each other, having safe places to go to in our day to day lives.
There's just another couple of practical things about senses that are self-care, is to remember what we don't have to do with trauma informed care, so we are not a journalist recording the story, we're not a lawyer, trying to get to the bottom of who's to blame, we're not a police person or a witness, who has to remember every detail and determine how much we believe it. We're not a judge who's determining any outcomes or a firefighter or a referee or a saviour. None of those are our jobs as GPs. Instead we have this unique amazing role of being with people as they heal and accompanying the amazing physiology of the human organism in community with meaning on the road to recovery.
You'll have something put into the chat box now, which is a resource, it's a PDF that was designed out of my PhD for clinicians during COVID and it has some key questions for you to be able to reflect on your own needs to make sure that you are managing the levels of arousal and threat in your environment, in your social climate, in your relationships, your body, your inner experience, your sense of self and meaning and spirit. I hope that resource will be something you can take away and reflect on after this session.
Dr Cathy Kezelman:
So trauma informed care, so how can you walk alongside other people and provide them with the support that they need, while caring for yourself, so that, as a community we can build a sense of healing and connection and shared strength in understanding and compassion.
Dr Johanna Lynch:
Wonderful and our last slide is further resources. The Deepest Well that we talked about there, my PhD turned into a book for Rutledge and then some fantastic resources from The Readiness Program, from talking about trauma series within Blue Knot, and the number story website that we've mentioned earlier, and the RACGP Abuse and Violence, Working with our Patients in General Practice, White Book, that will be published on the 30th of November.
Dr Cathy Kezelman:
Blue Knot training as well, if you want to dig deeper.
Dr Johanna Lynch:
Okay that's ready to go.
Fantastic, okay over to you Sue now to manage the questions. I think you had something in the chat box about whether Cathy and I would be happy for a PDF of our slides to go out. The answer from me is a yes, is that a yes from you Cathy?
Dr Cathy Kezelman:
I have to check on that sorry.
Dr Johanna Lynch:
That's all right.
Sue Gedeon:
That's fine just let me know, and I can email it around if it's a yes.
Dr Cathy Kezelman:
Yep.
Sue Gedeon:
So I think there was just one question about if they can share that PDF, the sense of safety self-care PDF, if that can be shared with their colleagues, is that okay?
Dr Johanna Lynch:
Yes, yeah great.
Sue Gedeon:
If anyone has any questions, please pop them in the Q&A box.
I think we're all good on questions. If anyone thinks of anything after please do email me I did put my email in the chat box earlier.
Oh a question has come through, is there a resource to look for trauma psychologists?
Dr Cathy Kezelman:
Blue Knot does actually have a referral database of therapists who we have gone through an application and assessment process to be trauma informed. So you can access that by ringing blue knot helpline 1300 657 380, sorry that's another unapologetic plug but it is, it is a list of trauma informed therapists.
Dr Johanna Lynch:
I'd also put a plug in for Blue Knot Foundation’s resources that are specifically designed for GPs that are available on their website as well.
Sue Gedeon:
Perfect. Another question is what kind of boundaries do you suggest for GPs when seeing patients suffering from complex trauma?
Dr Johanna Lynch:
I love the idea that boundaries are about being positive about what you will do and clear about that, that the clarity is actually a kind of kindness as Renee Brown says, who I learn from. And in this group of people have had people invade their boundaries and have not had good modelling in many cases, about what a normal distance that is normal between us and another person.
And so often we actually have to be more clear about boundaries with them then with some of our other patients who intuitively understand about boundaries because they've received and given them in their own lives. That, I guess, I found I've made mistakes of a time where I've changed my normal rules around these patients for the sake of what I thought was being kind, but actually what I was being was unclear. And so being clear for yourself what you will, and won't do, how much access you want your patients to have to you.
Over the years, my mind has got less more clear about when I’m at work and when I’m not at work. More clear about when I'm when on the right state of mind to listen and understand and process in that kind of clinical way. And when I'm off duty and I'm actually focusing on another way of being in the world and being clear about that right at the upset with patients, so when they first come to see me, how much access they have to me. As I've done less clinical work, more research and teaching, I have less capacity to be available, and so I have to make that very clear when they're making their decision about whether or not to engage with me at this time.
Dr Cathy Kezelman:
You know I think it's about setting the clarity of boundaries, because people who have experienced trauma often have had those boundaries violated, and I think clear boundaries when kept to help to keep people safe, and I think, even though people may initially not enjoy them I think they're actually very containing.
Dr Johanna Lynch:
A practical example like sometimes people will want to write emails to you, to actually make it very clear you won't be reading the email, other than when you're with them. So some people do find writing a way that's easier to explain what's happening, and they find it very difficult to put things into words. But then, to give them the dignity of reading that with them in the room and that's also protecting your own dignity, because you're not doing unpaid work outside of the room.
But it's also showing them how much you're taking note of what they're saying and not raising hopes for an instant response or relationship beyond the consulting room that can come from the confusion of sending emails and waiting for replies.
Dr Cathy Kezelman:
So some modelling safe boundaries, so when you haven't experienced safe boundaries it's very hard for you to gauge your own boundaries, as you go through the world, and I think if you have someone who's modelling them that can help you understand them even better.
Sue Gedeon:
Thank you. Another question is, how can I help people to feel safe when I am running late, and they have to wait? I worry a lot about this, stressing people and it just prevalent in general practice.
Dr Johanna Lynch:
I have actually found out a couple of my traumatised patients that their abusers used waiting as a way to torture them. So that they had to be on you know, on guard and the unpredictability about when the next thing would happen.
And so for a small subset of my patients, waiting is extremely triggering and so just having systems where it's okay for them to wait outside and smoke outdoors and you will come and get them. Things that acknowledge their bodies get agitated in the waiting room and that it's okay, we're not judging them, we don't need them to sit still like good kids in the front row of the school room.
And we're flexible about those things, but also the common courtesies of apologising when we're running late and acknowledging our mistakes in the process, you know, I often say I just didn't manage my first patient very well today and that went over and then that's led to you being kept late, I'm really sorry about that.
Dr Cathy Kezelman:
So hopefully who the reception is on the front desk informing people about what the wait will be because yes, the message that people can receive is that they're not valued. And they're not worth it, and so it's important to manage that. It's a reality of general practice that at times you do run late but it's about you know speaking openly and honestly about owning it, explaining it and helping someone to make sense of that it's not about them, not being valued.
Sue Gedeon:
Time is often a problem, how long should consultations be and what can be done to give patients sufficient time?
Dr Johanna Lynch:
Oh, this is my achy painy thing about working in the model of care we have with this group of people. And it's been an enormous personal cost for me in order to give time to this group of people. And I guess that I think is kind of a key thing about you working out what your boundaries are and what you will, and won't give in this space and being very clear and not over promising what you will give in terms of time and attention to someone.
And, in a way, I kind of think what's worse than getting no help is getting inadequate help because then it delays you getting adequate help. And so having clear referral pathways to people who know how to do this work and have decided to devote their life to it if that's not going to be your area.
And having ways that you communicate about complexity in terms of booking appointments, the way your receptionist manage your patients with what their expectations of time are and clarity around that even you know booking their next appointment. Booking planned appointments is a way to manage this group as well, so they don't come in a crisis, and you can you can do small tasks often rather than one large time slot.
Dr Cathy Kezelman:
Well it's about defining your role and, as you say, referring on to people who are doing the trauma work as such and establishing what you can and can't do.
Sue Gedeon:
And how do I ensure my patient safety, whilst I'm learning to be better trauma informed?
Dr Johanna Lynch:
Look, I've lived through this where my patients have been my main teachers, and the reality at the moment is there's not a lot of resources in this space and there's not a lot of well-trained therapists or psychologists in this space. Most of our psychologists have gone down the pathway of focusing on thoughts and behaviour rather than the sensory and relational tasks that are part of trauma informed care, and so our patients in my case, they were willing to teach me because there was nobody else.
It may be there's a sense of being open with them about the fact we're trying to learn. In your caseload in your neighbourhood depends on what's available. If you notice something available that could offer better care, then maybe work with them to do a shared care with those therapists or counsellors or psychologists in your neighbourhood.
Be open to other kinds of therapy that work EMDR and sensory motor therapies, and creative and expressive therapies, always that our body reconnect and helps us understand and make sense of what's happened to us.
Would you add anything Cathy?
Dr Cathy Kezelman:
No that's good.
Sue Gedeon:
Thank you, I think that's probably it for this evening. So thank you everyone for attending and we hope you enjoyed the webinar and thank you so much to our presenters Johanna and Cathy for sharing your knowledge and time this evening.
As I said before, if you have any more questions, please email them through and we'll answer them offline Thank you.
Dr Johanna Lynch:
Oh somebody has written a question about the role of the GP.
Sue Gedeon:
Did you want to answer that quickly?
Dr Johanna Lynch:
I guess so, I mean I think this is where we do need to be careful not to be drawn into being insurance managers and stay in our role, while we still have a role to report to these other authorities where it's not our job to do their work for them. And look, this is, I think you're right it's a tricky area where we get drawn in to do some of the tasks for the rest of the community but again, to remember who we are, why we're here is a key part of the story.
Sue Gedeon:
Okay, great.
Thank you, thanks everyone have a good night.